Split-liver transplants for two adult recipients: technique of preservation of the vena cava with the right lobe graft

Split liver transplantation: a single center experience

Background: Split liver transplantation is used worldwide and allows for an increase of donor organ pool, especially for pediatric recipients. Donor selection, some aspects of surgical techniques and long-term results remain to be important issues of split liver transplantation.

Aim: To analyze our own clinical results of split liver transplantation, basic principles of deceased donor selection and specifics of surgical technique.

Materials and methods: From May 2008 to December 2019, 32 cases of division of the deceased donor liver for transplantation to two recipients have been performed (64 split liver transplantations). Liver was divided into the left lateral section and the extended right lobe in 30 cases (“classical split”), and into the left lobe and right lobe in two cases (“full-split”). In 22 cases, the liver grafts were split in situ and in 10, ex-situ.

Results: In the recipients of left-side transplants (left lateral section and whole left lobe), the one-, three-, and five-year survival rates were 80, 80, and 60%, respectively. In the right-sided transplant recipients (extended right lobe and right lobe), the one-, three-, and five-year survival rates were 93.3, 89.4, and 89.4%, respectively (p = 0.167). The most probable risk factors for mortality in the univariate analysis were liver retransplantation (p = 0.047) and patient’s weight (p = 0.04).

Conclusion: For split transplantation, it is advisable to consider donors with a high-quality liver. This technique demonstrates satisfactory results and can be viewed as effective for patients with terminal liver diseases.

Current status and perspectives in split liver transplantation

Growing experience with the liver splitting technique and favorable results equivalent to those of whole liver transplant have led to wider application of split liver transplantation (SLT) for adult and pediatric recipients in the last decade. Conversely, SLT for two adult recipients remains a challenging surgical procedure and outcomes have yet to improve. Differences in organ shortages together with religious and ethical issues related to cadaveric organ donation have had an impact on the worldwide distribution of SLT. Despite technical refinements and a better understanding of the complex liver anatomy, SLT remains a technically and logistically demanding surgical procedure. This article reviews the surgical and clinical advances in this field of liver transplantation focusing on the role of SLT and the issues that may lead a further expansion of this complex surgical procedure.

Liver transplantation using low-weight recipients from a graft split program

We present our experience with a split liver (SL) program shared with the children's liver transplantation (LT) program from 2 different hospitals in the use of partial grafts from cadaver donors in brain death. We describe an observational, retrospective study, which included patients who underwent a SL transplantation in our center between January 2006 and December 2012. Clinical variables were recorded of both donors and recipients and their data were analyzed using SPSS 19.0 software. Of a total of 204 LT, 4 (2%) patients were treated with a SL. The causes of LT were alcoholic cirrhosis in 2 cases, cryptogenic cirrhosis, and primary biliary cirrhosis (PBC). In all cases there was a temporary portocaval shunt. The confluence of the hepatic veins of the recipient was anastomosed to the donor vena cava and arterial anastomosis was performed. The reconstruction was hepato-choledochal in all cases. There were no cases of postreperfusion syndrome or vascular thrombosis and no retransplantation was necessary. Currently, 3 of the 4 cases are still alive. Death in the other patient was due to mesenteric ischemia. Our center has participated in the development of a protocol that considers the indication of this technique provided expert groups are involved in its development, regardless of hospital level. This will expand the pool of donors and partially solve the current problems with available grafting.

An experimental study of triple split-liver transplantation in dogs

AIM: To explore the feasibility of a strategy of tripartition of a whole deceased liver graft for use in 3 recipients in dogs to ultimately maximize donor organ use.

METHODS: Adult healthy mongrel dogs were selected to be donors (n = 30, weighing between 20-25 kg) and recipients (n = 30, weighing between 8-15 kg). Donor/recipient pairs were randomly matched. For donor operation, transection of the parenchymal bridge was performed between the right lateral lobe and right middle lobe, and between the left middle lobe and the quadrate lobe. After in vivo perfusion, the left, middle and right liver grafts were procured, and their primary branches were cut near the main stem. Among the three liver grafts, the one was chosen to be implanted if it's GRWR (graft-to-recipient weight ratio) was more than 1.0% and was nearest to 1.5%. Recipients entered Groups A, B and C if the left, middle and right grafts were chosen, respectively. With the piggyback technique, the outflow orifice of liver graft was anastomosed to the anterolateral wall of the recipient vena cava. The graft was revascularized via reconstructed hepatic vein and portal vein, and then the hepatic artery and bile duct were anastomosed both in an end-to-end manner. Biliary and abdominal drainage was inspected postoperatively. Autopsies were performed promptly after recipients' death to investigate the possibility of technical complications.

RESULTS: By prominent fissures, the canine liver was divided into 7 lobes, among which the parenchymal bridges were thin. The parenchymal bridge connecting the right lateral lobe to the right middle lobe was much thinner than that connecting the left middle lobe to the quadrate lobe. No major conduit was found during transection of these two parenchymal bridges. The portal vein was split into three branches. The common bile duct was formed by the union of three hepatic ducts-the left, middle and right hepatic ducts. The hepatic vein consisted of the left, median and right hepatic veins. Anatomical variations in the hepatic arteries could be found. Among three recipient groups, the operation time, anhepatic time and blood loss did not show significant differences (P > 0.05), but the mean recipient weight, liver graft weight, and GRWR differed significantly (all P < 0.01). In the three groups, none of the recipients died during surgery. Once the hepatic vein and the portal vein were anastomosed and declamped, the implanted liver regained its color soon and its appearance returned to normal following arterial revascularization. There was no statistical difference in survival duration among the three groups (128.3 h ± 48.5 h vs 102.7 h ± 59.8 h vs 98.7 h ± 46.8 h, P = 0.234). Ascites and liver necrosis were not found at autopsy. Bile was present in the bile duct and all anastomoses were patent.

CONCLUSION: Our experimental results indicate that the whole liver of a big dog can be split into three parts, every one of which can be transplanted to a small recipient as an independent allograft.

Technical refinements and results in full-right full-left splitting of the deceased donor liver

OBJECTIVE

Splitting of the liver at the line of Cantlie of otherwise healthy people is accepted worldwide as a reasonable procedure for the donors in adult living donor liver transplantation. A similar operation is still considered as experimental if performed in the deceased donor liver. The aim of this study is to evaluate the technical evolution and the results of this variant splitting technique.

PATIENTS AND METHODS

From January 1999 to August 2004, a total of 35 transplants of hemilivers from deceased donors (segments V-VIII: n = 16 and segments (I)II-IV: n = 19) were performed in our center. Seven splits were performed in situ and 12 ex situ. Splitting of the vena cava was applied in 18 splits and splitting of the middle hepatic vein in 8. Seven adults and 12 adolescents received the left hemiliver with a mean age of 12 years (range, 3-64 years), of whom 21% were UNOS status 1. Recipients of right hemilivers were exclusively adults with a mean age of 48 years (range, 31-65 years), none of them were high urgent. The outcome of these 35 recipients of hemilivers was prospectively evaluated.

RESULTS

Mean deceased donor age was 27 years (range, 12-57 years), the donor's body weight ranged between 55 kg and 100 kg. The mean weight of the right and left hemilivers was 1135 g (range, 745-1432 g) and 602 g (range, 289-1100 g), respectively. The mean graft recipient weight ratio in left and right hemiliver group was 1.46% (range, 0.88%-3.54%) and 1.58% (range, 1.15%-1.99%), respectively. Median follow-up was 27.4 months (range, 1-68.3 months). Four patients died (actual patient survival FR group: 87.5% versus FL group: 89.5%), 3 due to septic MOF and 1 due to graft versus host disease. In each of the 2 groups, 2 recipients had to undergo retransplantation, which resulted in an actual right and left hemiliver survival rate of 75% and 84%, respectively. The causes for retransplantation were primary nonfunction in 2 left hemilivers, chronic graft dysfunction in 1 right hemiliver, and recurrence of the primary disease in 1 recipient of a right hemiliver. Primary poor function was observed in 1 recipient of a right hemiliver. Early and late biliary complications occurred in both right and left hemiliver groups at the rate of 37.5% (n = 6) and 21% (n = 4), respectively. Arterial, portal, and venous complications were not observed in either group.

CONCLUSION

The technical development of splitting along Cantlie's line is almost complete with the last challenge being the reduction of biliary complications. The key to success is the choice of adequate deceased donors and recipients. Full-right full-left splitting is safely possible and should be considered as a reasonable instrument to alleviate mortality on the adult waiting list and to reduce the need for adult and adolescent living donation.